Soiling (Encopresis)

If your child has bowel movements (BMs) in places other than the toilet, you know how frustrating it can be. Many parents assume that kids who soil their pants are simply misbehaving or that they're too lazy to use the bathroom when they have the urge to go.

The truth is that many kids beyond the age of toilet teaching (generally older than 4 years) who frequently soil their underwear have a condition known as encopresis. They have a problem with their bowels that dulls the normal urge to go to the bathroom — and they can't control the accidents that usually follow.

Many people mistakenly believe that encopresis is a behavioral issue — a simple lack of self-control. But punishing or humiliating a child with encopresis will only make matters worse. Instead, talk to your doctor, who can help you and your child through this challenging but treatable problem.

What Is Encopresis?

Three to six times more common in boys, encopresis isn't a disease, but rather a symptom that may have different causes. It affects only about 1% to 2% of kids under age 10, but problems with encopresis and constipation account for more than 25% of all visits to pediatric gastroenterologists (doctors who specialize in disorders of the stomach and intestines).

What Causes It?

Most encopresis cases are due to constipation. The stool (or poop) is hard, dry, and difficult to pass when a person is constipated. Many kids "hold" their BMs to avoid the pain they feel when they go to the bathroom, which sets the stage for having a poop accident.

So to understand encopresis, it's important to understand constipation.

There's a wide range of normal when it comes to having a BM. "Normal" pooping might range from one or two BMs per day to only three or four per week. A child who passes a soft, medium-sized BM without any problems every 3 days is not constipated. But a child who passes a hard BM (small or large) every other day is. So are other kids who may go every day, but only pass hard little balls and always have poop left behind in the rectum.

So, what causes the hard poop in the first place? Any number of things, including diet, illness, not drinking enough fluids, fear of the toilet during potty training, or limited access to a toilet or a toilet that's not private (like at school). Some kids may develop chronic constipation after stressful life events such as a divorce or the death of a close relative.

Although rectal surgery or birth defects such as Hirschsprung disease and spina bifida can cause constipation or encopresis without constipation, this is uncommon.

How Does It Happen?

Whatever the cause, once a child begins to hold in BMs, the poop starts building up in the rectum and may back up into the colon — and a frustrating cycle begins.

The colon's job is to remove water from the poop before it's passed. The longer the poop is stuck there, the more water is removed — and the harder it is to push the large, dry poop out. The large poop also stretches out the colon, weakening the muscles there and affecting the nerves that tell a child when it's time to go to the bathroom.

Then, the colon can't easily push the hard poop out, and it's painful to pass. So the child continues to avoid having a BM, often by dancing, crossing the legs, making faces, or walking on tiptoes.

Eventually, the rectum and lower part of the colon becomes so full that it's hard for the sphincter (the muscular valve that controls the passage of feces out of the anus) to hold the poop in. Partial BMs may pass through, causing the child to soil his or her pants. Softer poop may also leak out around the large mass of feces and stain the child's underwear when the sphincter relaxes. Kids can't prevent this soiling — nor do they have any idea it's happening — because the nerves aren't sending the signals that regulate pooping.

What Are the Signs of Encopresis?

At first, parents may think their child has a simple case of diarrhea. But after repeated episodes, it becomes clear that there's another problem — especially because the soiling happens when the child isn't sick.

As the colon is stretched by the buildup of stool, the nerves' have trouble telling the brain that it's time for a BM. If untreated, the soiling will get worse and kids may lose their appetites or complain of stomach pain.

A large, hard poop may also cause a tear in the skin around the anus that will leave blood on the stools, the toilet paper, or in the toilet.

Parents are often frustrated by the fact that their child seems unfazed by the poop accidents, which happen mostly during waking hours. Denial may be one reason for a child seeming calm — kids just can't face the shame and guilt associated with the condition (some even try to hide their soiled underpants from their parents).

Another reason may be more scientific: Because the brain eventually gets used to the smell of poop, the child may no longer notice the odor.

How Is Encopresis Diagnosed and Treated?

Call the doctor if your child has any of these symptoms of encopresis:

poop or liquid stool in the underwear when your child isn't ill

hard poop or pain when having a BM

toilet-clogging BM

abdominal pain

loss of appetite

The problem probably can be managed by your doctor. But if not, you may be referred to a gastroenterologist.

Treatment is done in three phases:

Emptying the rectum and colon of the hard poop. Depending on the child's age and other things, the doctor may recommend medicines, including a stool softener, laxatives, and/or enemas. (Laxatives and enemas should be given only under the supervision of a doctor; never give these treatments at home without first checking with your doctor.)

Helping your child begin having regular BMs. This is done with the aid of stool-softening agents. It's important to continue using the stool softener to give the bowels a chance to shrink back to normal size (the muscles of the intestines have been stretched out, so they need time to recover).

Parents also will be asked to schedule potty times twice daily after meals (when the bowels are naturally stimulated). The child will sit on the toilet for about 5 to 10 minutes. This helps kids learn to pay attention to the urges to go.

Reducing use of the stool softeners. As regular BMs become established, the doctor will decrease a child's use of stool softeners.

Keep in mind that relapses are normal, so don't get discouraged. Your child might get constipated again or soil his or her pants during treatment, especially when being weaned off of the stool softeners.

A good way to track your child's progress is by keeping a daily poop calendar. Make sure to note the frequency, consistency (hard, soft, dry), and size (large, small) of the BMs.

Patience is the key to treating encopresis. It may take anywhere from several months to a year for the stretched-out colon to return to its normal size and for the nerves in the colon to become effective again.

Looking Ahead

Successful treatment of encopresis depends on the support a child gets. Some parents find that positive reinforcement helps to encourage the child throughout treatment. For instance, put a star or sticker on the poop calendar for having a BM (or even just for trying to), sitting on the toilet, or taking medicines.

Whatever you do, don't blame or yell — it will only make your child feel bad and it won't help manage the condition. With lots of love, support, and reassurance that he or she isn't the only one in the world with this problem, your child can overcome encopresis.